(954) 462-6536

International Masters Hall of Fame Nomination Form For Honoree Consideration

International Swimming Hall of Fame

 

Nomination Form For Honoree Consideration

Masters Division

 

1 Hall of Fame Drive * Fort Lauderdale, FL 33316 * (954) 462-6536 * FAX: (954) 525-4031

 

(Please type or print clearly)

 

LAST NAME: ___________________________________________________________

 

FIRST NAME: ___________________________________________________________

 

NICKNAME: ____________________________________________________________

 

ADDRESS: _____________________________________________________________

 

TELEPHONE: ___________________________________________________________

 

DATE OF BIRTH: ________________________________________________________

 

PLACE OF BIRTH: _______________________________________________________

 

CITIZENSHIP OR COUNTRY REPRESENTED: ______________________________

 

IF DECEASED, DATE OF DEATH: _________________________________________

 

 

PLEASE INDICATE THE CATEGORY OF THE NOMINEE:

 

 

 __________ SWIMMER  __________ FEMALE

 

 __________ DIVER  __________ MALE

 

 __________ WATER POLO PLAYER

 

 __________ SYNCHRONIZED SWIMMER

 

 

(Additional copies may be made of this form.)

 

 

I.  WORLD RECORD HISTORY

 

 

 Number of individual World Records attained: _________________

 

 Number of relay World Records attained: _____________________

 

 

CHRONOLOGICALLY LIST EACH WORLD RECORD SET:  Include age groups,

event, time, date, location.

 

 

 

 

 

 

 

 

 

 

II.  WORLD CHAMPIONSHIP HISTORY

 

Number of Medals attained:    Gold __________

 

            Silver __________

 

            Bronze __________

 

     Other final placings __________

 

 

CHRONOLOGICALLY LIST THE WORLD CHAMPIONSHIPS IN WHICH THE NOMINEE

PARTICIPATED:  Include age groups, events, relays, results, times, records

established, games, position, goals scored, honors received, etc.

 

 

 

 

 

 

 

 

III.  REGIONAL RECORDS AND CHAMPIONSHIPS (ie: European Championships (LEN),

Pan American Games, etc.):

 

 Name of Meet:  ______________________________________________

 

 Number of Medals attained:   Gold __________

 

            Silver __________

 

            Bronze __________

 

     Other final placings __________

 

 

CHRONOLOGICALLY LIST EACH EVENT:  Include age groups, relays, times,

records established, games, position, goals scored, honors received, results, etc.

 

 

 

 

 

 

 

 

 

 

IV.  NATIONAL CHAMPIONSHIP AND NATIONAL RECORD HISTORY

 

 Number of National Championships attained: __________

 

 Number of National Records set:   __________

 

 

CHRONOLOGICALLY LIST EACH NATIONAL CHAMPIONSHIP ATTAINED:

Include events, times, scores, dates, locations, games, position, goals scored, honors

received, etc.  Place an asterisk (*) in front of each championship that was also a

national record.

 

 

 

 

 

 

 

 

V.  LIST SPECIAL HONORS AND AWARDS RECEIVED:

 

 

 

 

 

 

 

VI.  LIST INTERNATIONAL AND NATIONAL ORGANIZATIONS

AND ASSOCIATIONS ON WHICH THE NOMINEE SERVED OR WAS APPOINTED

 

 

 

 

 

 

 

VII.  LIST "MILESTONE" ACHIEVEMENTS OR "FIRSTS" IN THE SPORT WHICH

WERE OBTAINED BY THE NOMINEE:

 

 

 

 

 

 

 

VIII.  ADDITIONAL INFORMATION OR DIALOGUE WHICH IS HELPFUL IN

PREPARING INFORMATION FOR THIS HONOREE:

 

 

 

 

 

 

 

 

 

 

 

      Submitted by:

 

      _________________________

      Print Name

 

      _________________________

      Signed

 

      _________________________

      Date

 

      _________________________

      Telephone

 

 

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